Provider Demographics
NPI:1750614160
Name:HEATH, RAEGENE RAECHELLE (OTR)
Entity type:Individual
Prefix:MRS
First Name:RAEGENE
Middle Name:RAECHELLE
Last Name:HEATH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1978 ACORN CT
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9438
Mailing Address - Country:US
Mailing Address - Phone:317-839-4336
Mailing Address - Fax:
Practice Address - Street 1:1978 ACORN CT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9438
Practice Address - Country:US
Practice Address - Phone:317-839-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003477A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics